West Virginia Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

Qualification pathways

You can qualify through any one of these.

Initial Approval — OSA in Adults with Obesity (No Concurrent T2DM)

All of:

Patient is within the FDA-labeled age range (adults)
Diagnosis of moderate to severe OSA confirmed by sleep study within the past 12 months with AHI >= 15 events/hour
Diagnosis of obesity with documented BMI >= 30 kg/m² within the past 3 months (date and BMI result stated on request)
Patient has been prescribed or counseled on use of CPAP as a potential therapy
Patient has received counseling on chronic weight management (increased physical activity and reduced calorie diet) and will continue ongoing counseling during treatment
Patient is not receiving Zepbound in combination with other tirzepatide-containing products or any other GIP/GLP-1 class agents

Initial Approval — OSA in Adults with Obesity and Concurrent Type II Diabetes

All of:

Patient is within the FDA-labeled age range (adults)
Diagnosis of moderate to severe OSA confirmed by sleep study within the past 12 months with AHI >= 15 events/hour
Diagnosis of obesity with documented BMI >= 30 kg/m² within the past 3 months (date and BMI result stated on request)
Patient has been prescribed or counseled on use of CPAP as a potential therapy
Patient has received counseling on chronic weight management (increased physical activity and reduced calorie diet) and will continue ongoing counseling during treatment
Patient has concurrent diagnosis of Type II Diabetes Mellitus and has been trialed on a preferred GLP-1 (indicated for Type II DM) compliantly for three months with treatment failure
Patient is not receiving Zepbound in combination with other tirzepatide-containing products or any other GIP/GLP-1 class agents

Documentation to bring

Sleep study results within the past 12 months confirming AHI >= 15 events/hour
Documented BMI >= 30 kg/m² with date and results of most recent weight and BMI calculation within the past 3 months
Documentation of prescription or counseling on CPAP as a potential therapy
Documentation of counseling on chronic weight management (increased physical activity and reduced calorie diet)
If concurrent Type II Diabetes diagnosis: documentation of compliant 3-month trial of a preferred GLP-1 (indicated for Type II DM) and treatment failure
Attestation that patient is not receiving Zepbound in combination with other tirzepatide-containing products or other GIP/GLP-1 class agents

Quantity limits

all strengths — 30-day supply

Approval and renewal

Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight, Clinical improvement of OSA while on Zepbound (e.g., patient-reported improvement in daytime sleepiness, partner-reported reduction of snoring/pauses in breathing, reduction of AHI events). Patient must also tolerate at least 10 mg maintenance dose, demonstrate documented compliance, and continue reduced calorie diet and increased physical activity. Initial BMI, OSA diagnosis, and GLP-1 step-therapy requirements are not explicitly re-verified at continuation, and staying on a maintenance dose of at least 10 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Concurrent use with other tirzepatide-containing products
Concurrent use with other GIP/GLP-1 class agents
Patients with concurrent Type II Diabetes who have not failed a 3-month compliant trial of a preferred GLP-1 indicated for Type II DM

Policy note: Initial approvals may be authorized for 150 days. Further approvals may be granted for 6 months after all continuation criteria are met. All fills are limited to a 30-day supply. OSA confirmation requires AHI >= 15 events/hour (moderate to severe). CPAP must be prescribed or counseled — a full prior trial/failure is not required. Patients with concurrent T2DM must have tried a preferred GLP-1 (for T2DM) for 3 months with failure before Zepbound is approved. Reauthorization requires: documented compliance, tolerance of at least 10 mg maintenance dose, continued diet/activity plan adherence, clinical improvement of OSA, AND documented weight loss >5% or maintenance of initial 5% weight loss.

Policy effective July 1, 2025 · verified June 3, 2026 · source: download